Abstract
In this paper, I will explore the relationship between ideal (ITs) and nonideal theories (NITs) and bioethics. I explore the challenges we face in their implementation in the real world. I argue that there is no sole theory (IT or NIT) that can guide the multiplicity of real world cases and policies. If we consider there are a variety of possibilities, we should ask several questions: When should we use NITs and when should we opt for ITs? Are there appropriate criteria for making these decisions? Which are the valid uses or justifications for NITs? Is there a way to guide the decision-making process in real world contexts? This paper will try to answer the above questions. In the first part of this paper, I make some distinctions to present the theoretical arena and debate, and I propose five criteria that can help our decision making process. In the second part, I introduce two cases focused on reproductive rights-related problems in order to apply the decision-making process developed in the first part. The first one examines conscientious objection in the case of legal abortion in Argentina and the second one analyzes the case of research with pregnant women in countries where abortion is illegal. In one case, I argue that we ought to follow NIT, while in the other we should follow IT.
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Notes
- 1.
As I will explain in the paper, I will also use the terminology “more or less idealized” theories since I will defend a continuum between ideal and nonideal theories.
- 2.
All the debate of ITs and NITs – at least initially – seemed to focus on Rawls and he appeared to be the target of many of these analyses (see Valentini 2012). This paper is not exegetical. I will consider Rawls’s position only when it is relevant to my argument or when it illustrates a point.
- 3.
Hamlin and Stemplowska (2012, 48-49) hold this position, though they distinguish four broad approaches: (1) full compliance and partial compliance; (2) idealization and abstraction; (3) fact sensitivity and fact-insensitivity and (4) perfect justice and local improvement of justice. They make a categorical distinction between the theory of ideals (identification and elucidation of ideals) and the continuum of ITs and NITs that are identified with institutional designs.
- 4.
One of the debates examines the degree of “idealism or realism” needed. For the utopian position of G.A. Cohen (2003, 2008) principles of justice are altogether independent of factual constraints versus Rawls’s more realistic analysis (principles of justice are developed in response to human condition, moderate scarcity, and limited altruism (Rawls 1999, 22)). However, other realist’s positions exist, such as Waldron’s (1999), that consider Rawls to be too idealized for failing to consider reasonable disagreement about justice. Other political realists include power structures (Williams 2005; Geuss 2008). Regarding feasibility concerns, Gilabert (2017) provides a systematic approach to the relationship between feasibility and justice.
- 5.
I will use ideal theory (IT) and transcendental approach (TA) indistinctively, as well as nonideal theory (NIT) and comparative approach (CA). Robeyns (2008) also considers Sen’s terminology to be akin to IT and NIT.
- 6.
Gilabert explains Rawls never says that he has shown that his three principles are better than all conceivable alternatives (Gilabert 2008. See note 4, page 8).
- 7.
Whether Sen’s analysis of Rawls is correct or not goes beyond this paper.
- 8.
This is also the position of Robeyns (2008, 344).
- 9.
“The method of reflective equilibrium consists in working back and forth among our considered judgments (some say our “intuitions”), about particular instances or cases, the principles or rules that we believe govern them, and the theoretical considerations that we believe bear on accepting these considered judgments, principles or rules, revising any of these elements wherever necessary in order to achieve an acceptable coherence among them” (Daniels 1996). Reflective equilibrium is endorsed by several theorists, such as Valentini (2012, 6), and Gilabert (2012, 2017).
- 10.
Gilabert speaks of a perfectly just society (p. 15). Although he does not adhere to the need for a perfectly just society, he still refers to it. I do not think we need such a strong position.
- 11.
I follow Gilabert (2012).
- 12.
Robeyns also argues for a continuum from ITs (2008) (as the ultimate goal) to NITs. She claims “IT and NIT tell us what ideals we are striving for, how different principles of justice should be weighed against each other, how justice needs to be balanced against other values and how to deal with instances of widespread noncompliance” (p. 349).
- 13.
Mills explains that IT as an approach will utilize some or all of the following concepts and assumptions as its basic apparatus: an idealized social ontology (characterization of the human beings), idealized capacities (completely unrealistic capacities attributed), silence on oppression (historic oppression and its legacy in the present or current ongoing oppression), ideal social institutions (family, the economic structure, the legal system), an idealized cognitive sphere (a general social transparency will be presumed with cognitive as limited to biased of self-interest…) and strict compliance (Mills 2005, 168–169).
- 14.
I believe he is so critical because he is thinking of mainstream ethics or political philosophy where IT’s assumptions are uncritically accepted and their principles have absolute priority.
- 15.
For example, he says: “Nor does the simple appeal to an ideal (say, the picture of an ideally just society) necessarily make the theory ideal, since nonideal theory can and does appeal to an ideal also.” (Mills 2005, 171). Thus, at least tacitly, Mills accepts different levels of idealization in the NITs and that NITs can use ideals. So there are no “pure” NITs; they have different idealizations and assumptions too.
- 16.
She also specifies that the academic profession should correct the current academic bias toward ideal theory and do much more theoretical work to bridge the gap between IT and NIT (Robeyns 2008, 342).
- 17.
Robeyns explains that Dworkin uses this strategy (Robeyns 2008, 354).
- 18.
Regarding List and Valentini’s comment, Nancy Jecker in a personal communication suggested replacing right for a better descriptor such as a “good fit” with the assumption that more than one idealization might fit and things can fit better or worse.
- 19.
They distinguish between a theory that is abstract (it is silent on an issue), and a theory that is idealized (if it entails some simplifying or limiting falsehood about that issue (List and Valentini 2016, 19–20). I will not enter the debate between idealization and abstraction that goes back to O’Neill (1987).
- 20.
These loci are: i) the theory itself; ii) the conditions of application of the theory prescriptions (i.e., “if such and such conditions hold, then such and such follows”); iii) the justification of the theory. They provide two examples from Rawls’s A theory of justice. They argue that the often criticized “idealized” assumption of full compliance is not made within the theory itself, but occurs as part of the justification that Rawls offers for the theory. It is one of the assumptions made by the parties in the original-position thought experiment. So, it is an idealization at level three. And, they examine Rawls’s assumption that a society that exists under favorable historical and social conditions operates at the level of the condition of application of the theory’s prescription, which corresponds to level two. List and Valentini consider the first level to be the most problematic. The other two may make the theories less relevant to the real world because their prescriptions may not hold in the second case and they will be insufficiently justified in the third case. However, they do not pose the kind of threat level one does (2016, 20–21).
- 21.
Tessman states that she is aware of the shift in the line between what is attainable and what is unattainable. She recognizes the value in differentiating options according to gradations of probability, according to their possibility/impossibility, and according to whether they are individually attainable or only attainable if there is a collectivity of cooperating agents.
- 22.
She criticizes Rawls’s proposal regarding some of NITs’ conceptualization. She does not accept just war or punishment as relevant to NIT and claims that some of NITs’ issues are not sufficiently stressed, such as whether the principles of justice should be adapted or how to weight different principles of justice (Robeyns 2008, 346–347).
- 23.
See Amanda Roth’s contribution to this volume for a broader discussion.
- 24.
In this version, I will reorder them as I think they can be better explained, given the current analysis.
- 25.
I interpreted Rawls as suggesting these three requirements. (Rawls 1999, sect 2, 39, 69).
- 26.
The fourth requirement was taken from Simmons (2010, 18–19).
- 27.
See Erman and Möller (2019 for a more exhaustive analysis of feasibility.
- 28.
Gilabert applies his dynamic approach to what he considers the three dimensions of justice. He explains how normative desirability and feasibility interact at different levels of deliberation about the pursuit of social justice. He wants to identify demands that are both normatively desirable and feasible for each of the dimensions of justice. These dimensions involve normative claims about: DI: Core principles including evaluative and prescriptive principles; DII: Institutions and social practices; DIII: Processes of transformation (2017, 106).
- 29.
Gilabert claims that we can retain idealism about principles and realism about feasibility and combine them (Gilabert 2017, 95–96).
- 30.
Gilabert proposes a deliberative reflective equilibrium. For him, there is a logical sequence of the overall conception of justice (the final product has to exhibit logical sequence) and there is an epistemic back and forth that determines what to accept as the content of each dimension of justice. Gilabert raises the point that his account differs from Rawls’s. He speaks of three dimensions of justice (core principles/institutions and social practices/processes of transformation). He envisions progression from more abstract to more specific prescriptive judgments. (Gilabert 2017, 110–111, note 23).
- 31.
- 32.
I thank Joe Millum for this comment.
- 33.
For example, Robeyns considers action design and implementation as part of the nonideal work (2008, 343).
- 34.
Again in bioethics we work with the actual world which obviously is not ideal, but we can select some situations (in this case countries) which are “more ideal” in certain respects.
- 35.
The practice of providing legal abortions hardly exists (particularly in some provinces of Argentina).
- 36.
This has been the product of the long standing and difficult fight of different groups of feminists. See Bergallo (2014).
- 37.
Whether this terminology is accurate is a topic of discussion that goes beyond this paper.
- 38.
The NIT candidates are: A) the silent referral: it argues for an institutional and silent policy. CO should be reported to the Director of the institution without constraints and IO is accepted. The status quo is not bothered. The only requirement is to have a plan to solve the situation. B) The careful ruler: neither the silent referral nor IO is accepted. It admits a referral as a compromise position and asks for a proper regulation of the CO (i.e., quotas of CO, etc.) so it sets some limits on the CO and C) temporary prohibition: IO and CO should be forbidden in the public system. Note that the three candidates argue for different public policies that cannot be endorsed at the same time. (Luna 2015, 130–131). I selected the second NIT that sets limits, seeks transparency and respects both CO and the woman.
- 39.
Although I use careful ruler in the article published in 2015, it may be more accurate to speak of a careful administrator. I thank Ignacio Mastroleo for this suggestion.
- 40.
Note the level of violence against women that these kinds of actions imply.
- 41.
Moreover, in these cases, poorer women are generally the ones that need the help of the public system, women with middle- or high-socioeconomic standing find safe abortions through illegal routes.
- 42.
This drug was given to pregnant women in the 1960s without conducting prior research. Many children were born with serious problems and malformations in their limbs. Another example is DES or diestilestibestrol, a synthetic estrogen used in 1940–1970 to prevent spontaneous abortions (https://www.cancer.gov/espanol/cancer/causas-prevencion/riesgo/hormonas/hoja-informativa-des)
- 43.
The responsible inclusion of pregnant women in research was the focus of the Second Wave Initiative, which began at Georgetown University in 2009 (Heyrana et al. 2018).
- 44.
- 45.
This guideline is very important because it clearly sets the ethical elements that should be considered when doing research with pregnant persons. In addition, being a guideline endorsed the WHO gives it a global scope, thus it has had a lot of impact internationally.
- 46.
That is, where abortion for fetal malformations, for problems affecting women’s health and on demand are illegal or non-accessible.
- 47.
In fact, when trials with AZT and placebo to avoid HIV/AIDS perinatal transmission in Africa were denounced, guidelines (i.e. Declaration of Helsinki) that forbid placebo were revised. Angell (1997), Lurie and Wolfe (1997) who condemned these placebo trials were perceived as too idealistic and non-pragmatic (setting barriers to an already difficult and complex activity). Reconstructing this debate goes beyond the scope of this article but two sides emerged one more idealistic and the other more pragmatic upholding scientific standards.
- 48.
Particularly in some low and middle income countries where men may be more reluctant to use condoms.
- 49.
In a recent study of nearly 10,000 women in South Africa, among those seroconverted during pregnancy 11% passed the disease on to their children compared to 2% who were seropositive prior to pregnancy (PHASES 2017).
- 50.
In Africa, the same reasoning may apply to Ebola as no fetuses survived maternal Ebola and a higher proportion of pregnant-Ebola-infected women died (Heyrana et al. 2018).
- 51.
This is the case in Argentina and many other countries.
- 52.
In Argentina, this has gone on for decades without any problem. A similar situation happens with assisted reproductive technologies and abortions carried out in clinics when women have multiple pregnancies (Luna 2018).
- 53.
And if the drug proves beneficial, they will not enjoy the benefits.
- 54.
Through innovative practice or non-validated practice if first positive data are obtained. See Holzer and Mastroleo (2019). I thank Mastroleo for this suggestion.
- 55.
Note that Costa Rica had forbidden research for several years. Costa Rica approves regulations to restart medical research on humans. (n.d.). Retrieved June 12, 2019, from The Tico Times Costa Rica website: https://ticotimes.net/2015/07/22/costa-rica-approves-regulation-restart-biomedical-research-humans. See also Mora (2017).
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Luna, F. (2021). Ideal and Nonideal Theories: The Challenges of Decision-Making in an Imperfect World. In: Victor, E., Guidry-Grimes, L.K. (eds) Applying Nonideal Theory to Bioethics. Philosophy and Medicine, vol 139. Springer, Cham. https://doi.org/10.1007/978-3-030-72503-7_2
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